Guideline on individualized care for sepsis patients
Delhi: In a recent study published in the journal Critical Care, Jean-Louis Vincent and the team have equilibrated the new Surviving Sepsis Campaign (SSC) guidelines with individualized care.
Sepsis is a major cause of death worldwide, not least because complex interventions need to be provided within a short window of opportunity. Therefore, evidence-based guidelines for sepsis treatment are welcome, providing a common ground for all clinicians involved in decision-making regardless of their expertise.
Such guidelines should therefore serve as an overarching reference document. As previously stated, 'Guidelines are the product of an explicit, systematic approach to the evaluation and synthesis of available information on a particular clinical topic. They are not a compilation of truths but are a summary of what is accepted by the authors as the best available evidence at that time.
Following are the key recommendations:
- The authors recommend individualizing the timing of ICU admission. It should ideally be within minutes in severely ill patients but can be less urgent in less severe cases. No time limit is applicable for all patients. The decision may be influenced by the level of care available within ward areas and by ICU bed availability and, of course, by the physiological status and reserve of the patients.
- The authors recommend individualizing the decision to admit to the ICU. Many patients develop sepsis at the end of their life. Patients with palliative care orders and treatment escalation plans that preclude advanced organ support should generally not be admitted.
- The authors recommend individualizing the timing of antibiotic therapy. The administration should be prompt in the presence of septic shock but less urgent in less severe cases, enabling more time to perform investigations, confirm the diagnosis and likely source, and seek expert advice.
- The authors recommend individualizing the need for and timing of tracheal intubation, based on careful clinical assessment, including level of consciousness, respiratory rate, and work of breathing, hemodynamic status, and assessment of gas exchange. Delaying tracheal intubation may lead to respiratory and even cardiac arrest, with dire consequences, yet premature use of invasive mechanical ventilation can expose the patient to ventilator-induced lung injury, distant organ complications, and increased risk of nosocomial lung infection.
- The authors recommend individualizing respiratory settings in mechanically ventilated patients, including driving pressure, tidal volume and level of positive end-expiratory pressure (PEEP), aiming at the lowest possible mechanical power. PEEP could be adjusted to lung recruitment capacity.
- The authors recommend individualizing oxygenation targets, taking oxygen delivery into account. Exposure to high PaO2 levels may be associated with worse outcomes, except perhaps in necrotizing infections. Extreme oxygenation values (too conservative or too liberal) should generally be avoided.
- The authors recommend individualizing sedation therapies, recognizing that many septic patients need little or even no sedation. Tracheal intubation per se is not a sufficient indication for administration of sedative agents. Sedative agents reduce vascular tone and myocardial contractility, and may also alter immune function.
- The authors recommend individualizing initial fluid resuscitation. No single formula can be applied to all patients, as fluid requirements vary substantially (depending on the source of sepsis and preexisting cardiovascular function). This is particularly true for the suggestion to give at least 30 mL/kg of fluid within the first 3 h. A young patient without comorbidities is more likely to tolerate administration of a large volume of fluid than a fragile elderly patient with severe cardiac or renal disease.
- The authors recommend individualizing fluid therapy using dynamic challenges. Assessment of pulse pressure variation (PPV) or stroke volume variation (SVV) is possible only in deeply sedated mechanically ventilated patients with no spontaneous breathing. Alternative methods, including fluid challenges or passive leg raising, are therefore more widely applicable.
- The authors recommend individualizing the type of intravenous fluid administered. For example, albumin administration may be considered in an edematous patient with profound hypoalbuminemia or prolonged non-response to crystalloids.
- The authors recommend monitoring of chloride levels if saline solutions are administered. Saline solutions should not be banned, but one must keep in mind that liberal administration of saline results in hyperchloremia, and this may result in a worsening metabolic acidosis and renal impairment.
- The authors recommend individualizing the initiation of vasopressor therapy. Fluid pre-loading may be considered in less severe cases, whereas fluid co-loading parallel to vasopressor initiation should be preferred in cases of life-threatening hypotension or a low diastolic arterial pressure.
- The authors recommend individualizing arterial blood pressure levels. Although a mean value of 65 mmHg may be recommended as an initial goal, the optimal level may be higher in patients with a history of hypertension, atherosclerosis or chronic kidney disease. Conversely it may be lower in younger patients without previous vascular problems, in those with chronically low arterial pressure, or in whom adequate tissue perfusion is maintained.
- The authors recommend optimizing oxygen delivery, based on clinical assessment complemented by careful hemodynamic assessment including measurement of mixed (or central) venous oxygen saturation (SvO2) and even carbon dioxide-derived variables. A low SvO2 in the presence of a normal SaO2 indicates inadequate overall oxygen delivery to the tissues. More importantly, a normal or high SvO2 does not exclude tissue hypoxia.
- The authors recommend a multimodal approach to assessing tissue perfusion, including mental status, urine output, peripheral perfusion, and blood lactate levels, taking into consideration the physiological reserve of the patient.
- The authors recommend individualizing blood transfusion. Transfusion should be based not only on measurements of hemoglobin concentration, but on clinical evaluation including persisting signs of tissue hypoperfusion, and measurements of SvO2 and lactate.
- The authors recommend carefully measuring and monitoring the effects of any therapeutic measures undertaken and deciding whether or not to continue or adjust treatment accordingly.
Vincent, JL., Singer, M., Einav, S. et al. Equilibrating SSC guidelines with individualized care. Crit Care 25, 397 (2021). https://doi.org/10.1186/s13054-021-03813-0